Paraurethral Cyst in the Newborn
Prashant K Adivarekar*, Rakesh K Thakur**, Hemant Lahoti*
Paraurethral cyst, which presents as an cystic mass around the urethral meatus is a rare congenital abnormality in the female newborn. Although the reported incidence of the lesion is between 1 in 2000 and 1 in 7000 live female births, only 41 examples have been reported in literature. Management of this lesion is controversial. Surgical excision has been advocated but spontaneous rupture, aspiration or unroofing of the cyst wall has also been reported. We present our experience in the management of a case of paraurethral cyst in a newborn.
Skene’s historic presentation in the 1880 established the clinical significance of the periurethral ducts,1 obstruction of which may lead to cyst formation at the urinary meatus, the paraurethral cyst. Only 41 examples have been reported in literature, 37 of whom presented in the newborn period.2 Herein we report our experience in the management of a paraurethral cyst in a newborn girl with a review of the pertinent literature.
A 3 week old female newborn the product of a full term pregnancy and normal vaginal delivery was admitted with us for a swelling at the vaginal introitus, which was apparently increasing in size adding to the apprehension of the parents. Clinical examination revealed a 1 cm cystic mass on the anterior vaginal wall lateral to and displacing the urethral meatus to the right. The mass ovoid in shape and whitish in colour, with small vessels in the cyst wall. There was no obstruction to urination and no palpable abdominal mass was felt. An infant feeding tube could be passed easily into the urinary meatus. Routine laboratory test and radiological examination were normal. We performed unroofing of the cyst wall. Sterile milky white mucoid fluid was evacuated and the excised cyst wall were lined with transitional epithelium consistent with Skene’s duct cyst. The infant remains asymptomatic and the cyst has not recurred.
Vaginal cysts are not common particularly in the newborn. The histologic appearance of the cyst epithelium identifies the embryological origin as is discussed.
1. Mullerian duct system : Most vaginal cyst are of mullerian duct origin, lined with stratified squamous epithelium and originate anywhere in the proximal four-fifths of the vagina.3
Fig. 1 : Paraurethral cyst
2. Mesonephric duct system : Cysts derived from persistent mesonephric duct (Gartner’s) ducts are lined with cuboidal or low columnar epithelium and do not secrete mucus.4
3. Urogenital sinus derivative (Skene’s duct) : Paraurethral cysts arises from the periurethral glands and ducts that empty into the female urethra and are rudimentary homologues of the prostate there are between 6 and 30 paraurethral ducts as demonstrated by Huffman.5 The 2 largest ducts commonly are referred to as Skene’s ducts.1 Skene’s glands are well developed in the foetus and small child and do not change noticeably with adolescene. They secrete a small amount of mucoid material with sexual stimulation that serves to lubricate the urethral meatus during coitus. Occasionally, duct obstruction may lead to a cyst formation that presents around the urethral meatus. The cause of ductal obstruction is not known; however, it may occur secondary to inflammation.6 Dislocation of urothelium into an adjacent area resulting in blocking of the Skene’s duct may account for the development of paraurethral cysts.3
Only 41 cases of paraurethral cysts have been described till date, 37 of whom are in newborns.2 Only one case of bilateral paraurethral cyst has been described.7 Skene’s duct is lined with squamous epithelium but paraurethral may be lined with urothelium of squamous epithelium.3,6-9 Paraurethral cysts are slightly more common on the right side.2 All the cases were products of full term gestation and uncomplicated deliveries without any other genitourinary abnormality.6 Clinical manifestation are almost nil, however displacement of the meatus, difficulty in micturition or spraying of urinary stream may be seen.
There is no consensus on the treatment of paraurethral cysts. Cohen first reported spontaneous rupture in a neonate10 and hence a conservative approach was advocated, however the duration of conservative management is not clear. Current experience suggests that spontaneous rupture of the lesion in neonates is unlikely after 2 months of age and hence surgical intervention in the form of needle aspiration, marsupalisation or excision should be considered.2
1. Skene AJC. The anatomy and the pathology of two important glands of the female urethra. Am J Obstet 1880; 13 : 265.
2. Ceylan H, Hayri BO, et al. Paraurethral cyst: Is conservative management always appropriate? Eur J Pediatr Surg 2002; 12 : 212-4.
3. Kimbrough HM, Vaughan DE. Skenes duct cyst in a newborn: case report and review of the literature. Jr of Urology 1977; 117 : 387-88.
4. Blackwell WJ, McElin TW. Vaginal cysts of mesonephric duct origin (Gartner’s duct cysts) : report of 22 cases. Quart Bull Northwestern Univ Med School 1955; 29 : 94.
5. Huffman JW. The detailed anatomy of the paraurethral lesions in the adult female. 1948; 55 : 86.
6. Lee NH, Kim SY. Skene’s duct cysts in female newborns. Jr of Pediatr Surg 1992; 27 : 15-7.
7. Gottesman JE, Sparkuhl A. Bilateral Skene’s duct cysts. J Pediatr 1979; 94 : 945-6.
8. Phupong V, Aribarg A. Management of Skene’s duct cysts in the newborn girl. BJU Int 2000; 86 : 562.
9. Bergner DM. Paraurethral cysts in the newborn. South Med J 1985; 78 : 749-50.
10. Cohen HJ, Klein MD, Laver MB. Cysts of the vagina in the newborn infant. Am J Dis Child 1957; 94 : 322-4.
*Resident; **Lecturer; Department of Paediatric Surgery, BJ Wadia Hospital for Children, Parel, Mumbai - 400 012.